Several days ago, the African Leaders Malaria Alliance (ALMA) convened during the 26th African Union Summit to celebrate unprecedented progress against malaria in Africa. During the gathering, ALMA presented its annual Awards for Excellence to 13 African countries that have shown commitment, innovation and progress in the fight against malaria, with Eritrea being one of the distinguished award recipients. Importantly, the award underscores Eritrea’s general progress and success within health and development. Located in the fractious Horn of Africa, Eritrea has proceeded to become one of the few countries to have achieved the UN Millennium Development Goal regarding HIV/AIDS, malaria, and other diseases. Furthermore, its immunization and vaccination coverage rates compare quite favorably with much of the developing world. This paper highlights Eritrea’s approach and success within the areas of immunization, vaccination, and malaria prevention, placing them within the context of the country’s health efforts during its liberation struggle, while also outlining several ongoing programs that bode well for the future.

To begin, Eritrea’s recent efforts at vaccination, immunization, and malaria control arouse memories of the country’s historical attention to health and healthcare. While the first modern hospital was built during Italian colonial rule, the national focus on and commitment toward health began in earnest in the late 1960s and early 1970s, during the early years of the protracted war of independence. In developing a medically sound health system, the Eritrean People’s Liberation Front (EPLF) prioritized, “... proper nutrition; adequate and safe water supplies; basic sanitation; immunization; the prevention and control of endemic disease; health education and curative services” (Pateman 1990: 222).

Of particular note, the EPLF’s central hospital at Orotta (in Barka), and the pharmacy unit hold legendary, almost mythical, auras. The Orotta hospital was often described as the “longest hospital in the world” since it was built into the underground maze of trenches and tunnels, and it was the scene of thousands of operations performed by EPLF surgeons. Equally impressive, the EPLF’s pharmacy unit was made up of twenty-two members, and “...by the end of 1987 it was producing fourteen types of tablets and capsules – two million per month - and hoping to provide...for sixty percent of the population’s needs” (Pateman 1990: 222) Furthermore, it produced 44 different types of medical supplies, including infusions, intravenous fluids, syrups and ointments.

Discussing Eritrea’s health system during the pre-independence period, Sabo and Kibirige (1989) conclude that Eritrea remained unwaveringly “...committed to developing a needs-based health care system, which functioned efficiently well” and that through a careful, methodical selection of priorities and an allocation system for the distribution of scarce resources, the EPLF provided remarkably effective emergency services, primary care and preventive health services (Sabo and Kibirige 1989). Findlay (1989) also adds that the EPLF’s health care system was “...better than those of many already independent African states.”

Although many of these unique health-related efforts were underlying keys to Eritrea’s eventual liberation and embodied the EPLF’s commitment to the health of the population, at independence the country immediately faced destruction upon a mass scale. Specifically, “... everything was destroyed [and there were]...no roads, no electricity, no water.., no education...nothing was there.” Quite simply, Eritrea started from well “below zero.” Health, especially in regard to basic immunizations, vaccinations, and preventable diseases, was in a terrible state. For example, WHO data for 1993 show that only 32% of Eritrean children had received DTP3 immunization, while measles and polio coverage were a meager 34% and 32% respectively. The general period also saw a high malaria prevalence rate; in 1995, there were between 300,000400,000 malaria patients, and in 1998, approximately 500 people died annually from malaria. To put these figures into proper context, it is useful to consider Eritrea’s regional neighbors for similar categories. In terms of DTP3 immunization, 1993 WHO figures show Djibouti at 41%; Ethiopia at 28%; Somalia at 22%; Sudan at 49%; Kenya at 89%; Uganda at 56%; and Africa at 50%. Regarding measles coverage, Djibouti was at 41%; Ethiopia was at 28%; Somalia was at 21%; Sudan was at 51%; Kenya was at 84%; Uganda was at 57%; and Africa’s coverage rate was 52%.

Since the early post-independence period, however, Eritrea has remained staunchly committed to improving the health of citizens. Much like during its liberation struggle, the country has utilized multidimensional, cost-effective, pragmatic approaches, involving broad participation.

In regard to malaria, Eritrea has categorized the infectious disease as an issue of utmost national concern. Significantly, approximately 70% of the population live in endemic, high-risk areas, with the Gash Barka region bearing greater than 60% of the burden. Of note, the most common malaria parasites found in the country are Plasmodium vivax and Plasmodium falciparum. The former leads to severe disease and death, while the latter is the deadliest species of all malaria parasites infecting humans.

To control malaria, Eritrea has employed an assortment of strategies, including the promotion of national campaigns and community based-programs. Many programs have focused on providing extensive awareness and information, organizing focus groups, using preventative interventions, and encouraging the use of medical check-ups and medication. As well, control strategies have incorporated early treatment, indoor spraying, a focus on drainage and larviciding, mass distribution of insecticide-treated nets (ITNs), and a variety of source reduction efforts.

As a result of the multifaceted control measures, nearly 70% of children below age 5 now sleep under ITNs and over 60% of people own at least 2 ITNs. Additionally, national malaria incidence and deaths have declined dramatically. Across the 1998-2012 period, Eritrea’s malaria deaths per 1000 people at risk dropped by over 90%, while annual malaria incidence was reduced by over 85%. These rapid rates of improvement have led to Eritrea’s malaria intervention being described as “the biggest breakthrough in malaria mortality prevention in history.”

As with its national malaria intervention, Eritrea’s approach to immunization and vaccination has been practical and cost-effective, ultimately leading to laudable, tangible outcomes. According to UNICEF, “immunization remains the single most feasible and cost-effective way of ensuring that all children enjoy their rights to survival and good health.” Notably, for a developing country such as Eritrea, preventative vaccinations and immunizations are critical since they help avoid expensive treatments for illness. Additionally, immunization programs are important since they can boost a country's general growth, with many analyses illustrating positive economic impacts.

Eritrea’s approach to immunization and vaccination has been based upon an array of cooperative agreements with various international organizations and partners, including the United Nations Development Programme (UNDP), UNICEF, the WHO, and the GAVI Alliance. These partnerships have increased supplies such as vaccines, syringes, and vitamin A capsules, while strengthening support for the development, production, and dissemination of social mobilization materials, regional plans, and logistics. Crucially, the Eritrean government has also encouraged the expansion of outreach facilities, organized mass volunteer campaigns, and generally exhibited a high commitment to “achieving financial sustainability and full ownership of vaccine financing.”

Ultimately, the result has been that more people – particularly vulnerable populations, nomadic peoples, and women and children in rural areas– have received important vaccinations and immunizations. As testament of Eritrea’s immunization and vaccination efforts and effectiveness, consider its DTP3 coverage figures. DTP3 is amongst the most prominent immunization series, and helps to prevent diphtheria, tetanus, and pertussis (whooping cough). Administered in 3 separate doses for infants (at one month, one month and a half, and three months), DTP3 coverage rates provide a rough, yet quite useful, gauge for how effective a country is in providing immunization for children. According to the WHO, in Eritrea, DTP3 immunization coverage has been at 99% since 2008, while its average immunization for the years 2000-2012 was above 95%. By comparison, average DTP3 immunization figures across the years 2000-2012 for Eritrea’s neighbors were as follows: Djibouti at 74%; Ethiopia at 46%; Somalia at 37%; Sudan at 78%; Kenya at 81%; Uganda at 67%; and Africa at 64%.

Notably, Eritrea’s impressive immunization coverage rates are not restricted to DTP3. In 201213, Eritrea’s measles coverage was 99%, well ahead of its neighbors: Djibouti was at 83%; Ethiopia at 66%; Somalia at 46%; Sudan at 85%; Kenya at 93%; Uganda at 82%; and Africa at 73%. Furthermore, in terms of polio immunization, Eritrea boasts a 99% coverage rate while rates for its neighbors are: Djibouti 81%; Ethiopia 70%; Somalia 47%; Sudan 92%; Kenya 82%; Uganda 82%; and Africa 77%.

Eritrea’s rapid improvement in immunization, vaccination, and malaria intervention has been the result of a capacity to adapt, community buy-in, effective coordination, resourcefulness, mutually respectful partnerships, cost-effective projects, and extremely hard-working volunteers and employees. Importantly, however, the country has begun to build upon its past successes and in recent years has started to implement expanded services to better ensure the health of citizens.

For example, Eritrea has introduced the Pneumococcal and Rota Virus vaccines. The Pneumococcal vaccine combats diseases such as pneumonia, meningitis and febrile bacteraemia, as well as otitis media, sinusitis and bronchitis, while the Rota Virus vaccination will aid in fighting rotaviruses, which are the most common cause of severe diarrheal disease in young children throughout the world. In terms of malaria, the country has renewed its commitment “to [completely] eradicate malaria prevalence,” officially proceeding to a new stage of malaria intervention and entering a pre-elimination phase via a 2-3 year period of consolidation. As part of the new phase, the country has begun to develop performance management systems at national, zonal and sub-zonal levels. In addition, the pre-elimination phase features a strengthening of malaria diagnosis and treatment measures at health facilities, and an expansion of optimal logistical capacities in each zone for targeted malaria elimination interventions.

Overall, with a sustained commitment to effective immunization, vaccination,and intervention programs, as well as ongoing support from international partners, Eritrea can continue to improve the health and development of its greatest asset –its men, women, and children.